Random thoughts from a few cantankerous American physicians. All contributors are board certified. Various specialties are represented here. I do not know where this will lead but hope it will at least be an enjoyable read. All of the names mentioned in this blog are pseudonyms, the ages have been changed, and in half the cases the gender as well. All photographs are published with patient consent or are digitally altered to preserve anonymity. Trust us, we're doctors.

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Sunday, June 24, 2007

Panda Bear, MD had a very interesting post on primary care medicine up on his blog recently. He is currently an EM Resident after spending a frustrating year training to be a Family Practitioner. He also brings his characteristic USMC sense to the subject of chiropractic 'medicine', but I will not comment on that here except to say that I agree with him.

Something terrible has happened to internal medicine and family practice in the past decade. Traditionally, internal medicine was considered to be "adult medicine" and family practice physicians had, as the name implies, mastered a broader knowledge base including pediatrics and Ob-Gyn. Necessarily, they sacrificed some detail for the sake of a broader base. In that regard, they were, arguably, the forerunners of the Emergency Physician. I used to explain what I do to by telling people I would be "like a family practitioner specializing in emergencies".

Twenty years ago, when I was a medical student (and then a resident) the internists were jumping over each other to get procedures, to put in central lines, and to run codes. Their training was rigorous and I decided against internal medicine because of the level of detailed knowledge required. I liked the immediate gratification of procedures and emergency care but I didn't care a lick for long-term management. I knew that the fine points needed someone with more focus than I could produce consistently. Also, general internists, twenty years ago, only called in the specialists, well, for special cases. They ran codes and managed patients in the ICU and did it well.

I have always viewed internists, especially the ones I trained under at medical school, as upholding the best traditions of medicine. Within their ranks were some of the most brilliant people I've ever met, doctors who emanated knowledge and compassion and who taught me, well, that I shouldn't be an internist.

However, since the specialty of Emergency Medicine has become a prominent player in almost all major hospitals, the internists and generalists have stopped taking care of critically ill patients. They have also stopped taking care of "unstable" patients. They only care for patients after they have been "stabilized", usually by a combination of EMS and Emergency Physicians and Nurses. Or, they take patients in transfer from the ICU or SICU where an 'intensivist', usually a pulmonary/critical care specialist, has directed their care.

So what do the general internists and family practice docs do these days? They manage chronic diseases like diabetes and hypertension, they provide early diagnosis of many conditions with insidious onset such as cancer, arthritis, and lymphoma . In smaller communities they may still do some orhtopedics, some psychiatry, and, in fact, the whole range of non-surgical care. I'm sure that some family practitioners still (foolishly given the malpractice climate), deliver babies.

Most generalists have been forced to employ midlevel providers (Physician Assistants and Nurse Practitioners) to see enough patients to make enough money to make any money. Many times, they don't really see patients anymore but merely provide oversight.

Now, what happens if you have chest pain? If you go to your general internist's office and he or she finds out you have risk factors for cardiac disease and are over 30 you will likely find yourself in an ambulance on your way to see me. If you call the nurse "answer line" they will tell you to go to the "nearest emergency department". Or, you may choose to come directly to me.

What if you need quick lab results? What if you have vomited yourself into dehydration and need an IV? Go to the ED.

What if you have abdominal pain and call your physician or even your surgeon if you have one? They will tell you to come to the E.D. for evaluation. After all, where else can you get a STAT CT scan? Is there still a surgeon in the United States that will take a patient to the operating room based on a clinical exam and patient history?

If you call the nurse line you will get the same response. Or, you can eliminate the middle-man and just come on in. Bonk on the head. E.D. Laceration? E.D. Vomiting blood? E.D. Medication adjustment? Call your internist for a follow-up three or four weeks from now or come on in.

I am not happy about this situation and I am not criticizing internists or family practitioners in that I do not think that this was planned or desired. I think that internists know more about medicine than I ever will or care to, but what are they going to be doing ten years from now? We have made it easy for them to opt out of high liability care and they have opted.

The reality of it has been striking especially since, at our facility, our hopsitalists (internists who confine themselves to hospital practice) have begun demanding 'complete workups' prior to admitting a patient from the E.D. Rather than taking Mr. Smith, with unstable angina, directly upstairs after initial stabilization in the ED, they now won't take him without all his tests being complete including his CT of the chest and his horizontal stool-velocity. If a test is pending when a patient is sent upstairs I am sure to hear about it as an 'incomplete workup'. Well damn!

When the E.D. is popping and the E.M.S. crews are bumping into themselves in the ambulance bay the best thing I can do for everyone is to stabilize and move the patients. If it's not so bad then I always complete my workups and always review the patient's prior admissions. But not accepting an admission because the diagnosis is in doubt or the workup is partial? I mean I know there's lots of paperwork to do but to call me upstairs to do a lumbar puncture on a patient admitted three days ago? Can you really not do one? Didn't you do them in medical school? Internship? Residency?

By insisting on this level of completeness from me the hospitalists, internists, and many surgeons have aced themselves out of caring for the critically ill and are losing their clinical judgement and skills for lack of use. In the meantime my skill and knowledge base is increasing. Hell, internists in my town don't even manage the sorta-ill or the kinda-ill anymore. Like most things in life, true gut-knowledge comes through repetition. If you haven't run a code in three years then I understand why you don't want to run one today. I don't know why they don't see this but they don't. Job security for me? Sure. But I'd rather do Emergency Medicine.

43 comments:

Wow 911, I had to rest halfway through reading this. But you are right again. I can know 93.5% of the time whether someone will require admission within 5 minutes of seeing a patient and hearing their story. They need to get upstairs as soon as I feel I've done everything I need to do, not when the freaking workup is finished.

I have stable Type 1 diabetes with an insulin pump (no complications, excellent Hgb A1c) and my family practice MD refused to see me for my diabetes after two 6-month visits. She said she'd no longer write for my scripts and all my diabetes care should be done through an endocrinologist (I called around to find one that was accepting new patients in my area--it took a few calls--some were booked 4 or 5 months in advance...dude, I can't wait 5 months for my insulin).

Whither the generalist, yes. I even said I thought the cost of a specialist and the wait for a specialist would give me no added benefit, and she still said she wouldn't see me for my diabetes.

I work in an ER and while I'm certainly not surprised; I stand right smack in the middle of what is going on between family medicine and ER medicine.

On the one hand, the frustration in me builds as we hold patients longer and longer in the ER so the family practioner can have a complete work up before his patient arrives to the floor. In many cases, by the time the ER has done what the family practioner wants us to do, we could probably discharge the patient. In the meantime, those "stable" patients are moved out into the hall so we can move more severe patients into rooms and examine them more completely. (I'm so glad HIPPA set up a law that encourages us to keep things on the low down. I'm sure nobody else but the patient can hear his diagnosis being told to him in the hall.) Of course, the patient is not "completely" taken care of until the nurse has taken 2 pages of orders from the PCP which only takes about 15 - 20 minutes of my time. I'm sure the sick and dying can spare the time.

Why do I feel that I stand right in the middle? My daughter practices Family Medicine. (Residency Graduation is Friday.) We've had long talks about why she choose that particular field. Her reply humbles me. "Mom, I want to be able to take care of babies, their parents, and grandparents. I want to take care of the whole family unit. I don't want my patients running to the ER for coughs/colds/pain medicines. I want to know them. I want to know why they need things. I want to take care of them. Is that so bad? Is that such a horrible thing? I know there are things that I can't fix, that at times they will need the ER, but most of the times they don't. They need to see me, not some doctor who treats them temporarily and then all of a sudden the patient decides tht the ER doctor should become their PCP. ER docs are for emergencies. I should be the glue that holds everything together."

Maybe I'm just being a Mom (I hope not), but I wish more family medicine doctors would feel this way. Yes, I know, she's 27, young and innocent; but I can't help but hoping she will stay "forever young."

doc911,after a grueling shift last night (once again, many freaks), upon pulling up your most recent post, I thought, "this is probably going to be over my head." I'm glad to say, it's not. If fact, one of the things that frustrates the hell out of me is triaging a pt with the cc of, "Dr. Jackass sent me." I always bite (do I have a choice?) "Why did he send you?" "My potassium is low." Ok...surely he could have given this person a Rx for freaking KCL, no? I think they do have that capability...or actually, this one if my favorite, "Dr. Asshole sent me." (As usual, I bite)--"Why did Dr. Asshole send you?" "For the infection in my foot." Sure enough, looks like cellulitis to me! And I didn't even go to med school! Alright...if Dr. Asshole thinks you need IV ABX (and she's probably right), why in the hell didn't she admit you to do it??? Because they have gotten too damn lazy and want their damn banker's hours! They are only there during business hours...ER docs are there all the time as are the hospitalists. They really piss me off because I think they are greatly taking advantage of EM!Hell, I even had a pt who came straight from one guy's office (well, not straight from, he had to go home, pack and then stop for something to eat) before coming to the ER on his PCP's order because he was in "heart failure." I asked the pt how did his PCP know that he was in failure? The pt replied, "He just told me." Now granted, the guy was a train wreck and had been for a LONG time, was edematous, lungs sounded like crap,sob (but not really far off from his baseline quite frankly." The pt came with 2 packed bags in preparation for his stay. We did the million dollar workup only to send his ass home! What the hell? Just because this guy showed up on the advice of his lazy PCP!I guess we should be grateful for job security. Between the dumbasses/freaks, and lazy PCPs...we will never be without a job.

hey, my own woman,congrats to your daughter, you must be so proud! What a lovely attitude she has. My wish for her is that she is a freak of nature and will hold that attitude always (well mostly!) Unfortunately, she is probably human and will become extremely frustrated by people who come to her with problems and continually choose to completely ignore her recommendations on how to solve or manage their "health" problems.

I get caught in the middle of this issue all the time. I'm a home health RN and routinely call doctors about the status of their patients--- and lots of times it's an obvious need for admission to the hospital. But even when it's something which could be solved by a simple office visit, 9 times out of 10 the town doc listens to me... and then says the following in a guilty, whispering type voice:

"Send her to the ER. And.. Bo, don't tell them I told you that. Just tell 'em it was YOU who thought she ought to go to the ER- --they'll call me when she gets there anyway."

And what's worse is that the ER docs KNOW this is what's going on---and ocasionally they get really angry...

Example: I find a fist-sized abscess on an elderly patient's torso, fever of 103---and call the patient's doctor. He tells me to send the patient to ER, adding: "tell the ER she needs a surgical consult". The ER got mad and hollered at me, saying: "Tell him to get his own damn surgical consult!" and sent the patient home with a diagnosis of "cellulitis" and orders for us road nurses to give the lady a 5-day course of antibiotic IM's.

36 hours later, the patient was worse. This time I sent the patient into the ER on my OWN decision, and I faxed the ER a written explanation of how the patient was worse to bolster my verbal report.

The patient was then admitted, worked up, vented the next day, ICU'd, placed on dialysis---and never went home. She was dead within a few weeks.

I'm not saying the patient would have died or not died either way, no matter what was done. All I'm saying is that I don't like to be caught between the two sides.

And what realisticrn said about the town's docs liking their "bankers hours"? That is soooo true. Almost every single Podunk doc closes at noon on Fridays, all year round, and some have "summer" hours where they close at noon on more than just one day a week....

Where did this disconnect come from? I, and my cohorts in the midwest must be freaks. We all think the ER is for, well, emergencies. You know, when you think someone might be dying or dead?

nurse k, you need a new PCP! I think, perhaps, that PCP is shirking her responsibility to you. It is not impossible for someone who is on a maintenance schedule to have once yearly (or whatever is appropriate to the disease) appointments with the specialist with the majority of issues dealt with by your PCP. Even those of us with chronic illnesses get regular illnesses too.

Something is seriously askew when people - including medical personnel - see the ER as primary care.

Fuckin' Tolstoy, you could have done 12 LPs in the time it took to write this post.

I jest.

If I can turf all my pain-in-the-ass patients; maintain low liability; and have good working hours, well, guess what...

The existing incentives allow people to treat the ER like dog-shit. Why get 'gut-knowlege' by repetitive procedure performance when I am marginally paid and expose myself to liabilities? The bleeding hearts will say we do it for 'compassion' or some other buzz-word. Because of existing laws, sitting at the bottom of the shit-slide is you. The greater the government involvement in regulating medical care, the more fucked up this will get.

My wife wants to know what your name stands for. I know, but I just wont tell her. She follows the blog every day, and as you know from her drunken state and broken foot at your wedding, she has a tough time figuring things out. She loves your posts. And you too, 911.

Hey there...I enjoy your blog. Just wanted to chime in to let you know that I operated on a young man today (for appendicitis) without a CT. I am happy to do that for a good story/exam, and try to use the CT judiciously (like a consult, it works best when you have a specific question in mind). Unfortunately, I know where you are coming from, as I have had colleagues that insist on the CT.

Jen

PS: I think it is awesome that I got "ernia" as my verification code, as I fix lots of hernias and have a pet named Ernie. psychic computer!

Perhaps Etotheipi could assist me in figuring out why you are a cat, yet have UnderDOG as your avatar.

Re: whithering generalists....those at the Spa have already shriveled up and died. All they do now is to send consults for each and every thing. Clearly atypical non-cardiac CP reported during an office visit? Forget doing an EKG, VS assessment, or a focused hx. Straight to the ED, do not pass go, do not collect $200.

Cat: I must continue the mutual onanism. This is the greatest blog I've seen - O.K., the only blog - but the posts are great. Tell your lovely wife to check out Euler's Identity - that's all I'm sayin'.

RG: Stalkers welcome! Maybe it's weird that I like people watching me go to the bathroom, but that's just my thing.

911 doc:I don't know where you work but I suspect you need to get out of that box called the ER and walk around the hospital a little to see what is really goes on. I'm a hospitalist. I manage pt's in the ICU. I run codes, I place lines, I do LP's. For every horror story about an IM/FP doc I can give you a horror story about an ER doc (but not limited to) doing the following: Admitting pt's with no risk factors having clear MS type chest pain", missing an obviously present fracture, not appropriately evaluating a trauma, c/s to determine whether a pt needs an admission just to make sure another doc's name is on the chart, refusing to see pt's that left AMA and have come back to the hospital because "they should just be readmitted", etc, etc. I could go on and on. Unlike you, I don't blame a whole specialty rather just the lazy ones in it.

dear anonymous. i do get out of the ER on a daily basis, to run codes and do the occasional LP for our hospitalists (and for our our critical care guy who is never around for some reason). all i can say is, please come work at my hospital.

to whom it may concern- has anyone considered the fact that plenty of community PCPs have been marginalized by the endless accreditation/certification processes foisted by administrators, nurse managers - who left the job of triaging and frontline nursing to the cloud-minded antagonists of PCPs here?

cardio-np says "Clearly atypical non-cardiac CP reported during an office visit? Forget doing an EKG, VS assessment, or a focused hx. Straight to the ED, do not pass go, do not collect $200."

atypical chest pain that is actually ACS is one of the most common reasons for a malpractice lawsuit. "atypical" symptoms can be the real deal especially in diabetics.

this is why almost anyone who enters the ER with a cc of chest pain will ultimately be admitted.

and a spot EKG (especially without a baseline) tells you nothing if the patient isn't actively having pain at that moment. same for vitals, even WITH pain - if someone has cardiac chest pain & abnormal vitals they are already far gone & probably need to be in a CCU.

why don't you practice on your NP license & see what happens the first time you miss a cardiac chest pain? or a gastroenteritis that turned out to be appendicitis? or a URI that developed meningismus?

people just love to talk about what they don't know about, especially those who are undertrained & then thrown into the ring & expected to wrestle with the big boys.

Atypical chest pain symptoms can be the real deal in ANYONE, not just diabetics.

But in your blindered view, in which you appear to think that NPs are ignorant idiots, you failed to appreciate my point. I stated that pts with CLEARLY atypical non-cardiac chest pain were sent for unnecessary evaluation. In part due to the fact that the whithering generalist did not take the time to get an appropriate history and determine that the symptoms were not cardiac.Fleeting sharp pin pricky pain occuring at rest 2 months ago does NOT require an ED visit. Yet have seen a pt sent to the ED for this.

Your moniker is a bit incongruous as you seem perhaps more angry or bitter than happy.

Weren't FP's spending the last couple decades fighting, and losing, privilege fights over just about everything in the hospital? Surgery, endoscopy, obstetrics, ER, nursery, ICU, on and on.....

A lot of FP's decided since they aren't deemed smart enough to do anything in the hospital, why not stay in the office and max out what you can do there? Which, by the way, in my office at least, means a CLIA-moderate lab where I can do all that stat work, and I run my own IV's for the dehydrated patients.

Personally, (I'm a FP) I still do my own hospital work. I do my own office work, without mid-levels. My father was referred to a neurosurgeon last week and got seen by the neurosurgeon's PA. My mother gets treated by the cardiologist's NP. And I had to diagnose my mother's ACE-inhibitor angioedema by telephone several states away, missed by the "cardiology-NP".

That you see less generalist involvement in hospitals is unfortunate, but hardly surprising to anyone who has practiced in the last 20 years.

how many patients with CLEARLY atypical chest pain actually have ACS? the answer is probably more than you think.

and as a "withering generalist" i believe i have a bazillion more years of training than you, and was probably able to glean more cardiology out of my 6-months combined in a CCU & telemetry floor during residency than your entire career.

I don't think NPs are ignorant idiots at all - in fact i work with some WONDERFUL NPs in geriatrics, to whom I'd trust the care of my own family assuming they're being adequately supervised by a physician.

I do, however, take issue with the NP who feels, as you apparently do, that she knows more than the "withering generalist" who graduated at the top of his class in high school, went ivy league for 4 yrs, then 4 yrs of med school, then 3 yrs of a grueling residency, then hung out a shingle and started a solo practice, only to be downtalked by those with far less knowledge, training, and intelligence.

And I am indeed happy overall (thanks for your concern), just not with what has become of primary care - don't you think that the future is grim for EVERYONE in medicine when it's not just insurers/pharma/malpractice ruining primary care, but other physicians are too???

this is where there's an ER crisis in the first place - because nobody is doing primary care anymore! but you go ahead and continue to keep your head in the sand, & just deal with bullshit rule-out MI cases & administering stress tests for some jerkoff ripping off medicare & running a procedure mill. ignorance is bliss.

one more thing - your statement that "an appropriate history" to "determine that the symptoms were not cardiac" in itself makes my point - you need to go back to cardio NP school (what is that, like 6 weeks?)

"specialist" NPs and PAs need to remember that just because they work for a specialist MD they do not automatically have all their boss' knowledge & judgment magically imparted on them. Humility comes in handy, especially when you're in a crunch and you don't know a lick outside your "specialty" - you might then need the help of a doctor.

Or perhaps you can go solo & practice as a cardiologist? then let's see if you send your atypical chest pains to the ER or just sit & wait for the 5% of them to have an MI.

Do you even think about how your supervisors can afford to pay your inflated 'specialist' salary?

Is it part because of the referrals that your group gets from the primary care physicians you denigrate?

The state of primary care is so messed up that there is no real good derived from trying to diagnose ACS in the office! What about compensation for EKGs? Do you realize how much more it is if done by a cardiologist or his/her office than by a generalist? The $200 your group gets for that EKG passed on by the referring PCP helped compensate your inflated salary and blow up your ego...Talk about the fly sitting on an elephant's back, believing he is bigger than the beast he is sitting on...the arrogance this begets! Think about it!!! That is, if you have any more thinking and feeling cells not consumed by your ego and arrogance.

Your observations about the changing face of generalist medicine are dead on. And though the romantic notion of the one-doctor-does-all appeals to all of us, it's an impossibility. Ok, maybe an improbability. Why?

1. Medical knowledge is expanding so rapidly. Keeping up with outpatient care standards is about as much as I can handle. Maybe I could handle inpatient. But certainly not critical care on top.

2. As Panda has discussed so much more eloquently than I, there is a no-error standard in medicine these days. That's why the 28 year olds end up in the ER with chest pain. Not because I really think they're having an MI.

3. Primary care ain't the only ones with banker's hours. If there's a rectal abcess at 4:30 on a friday afternoon, every surgeon I call would tell me to "Send 'em to the ER."

I, with many of my colleagues, have embraced the "new" family medicine. I have a great outpatient practice, I work hard to keep my patients healthy as long as possible, and when I think they need to be there I send them to the ER. (I always call, by the way, even when I feel like a schmuck for sending them in.)

And I don't apologize for my banker's hours. It's about all we in primary care have left.

Dearest Happy,In fact, you don't sound so "happy"...maybe you need a little trip to your local ER for some "happy pills." Oh say, how about some Lortab or Dilaudid...Really, you should be very proud of yourself that you accept calls in the middle of the night about YOUR patients when they are actually sick enough to be admitted to the hospital. That is probably why they come to you (either that or are assigned to you through medicaid...) But here's the thing...I did't go to med school because of the commitment that was required. Yes, I do a 12 (+!!!!) hour shift and sometimes without breaks (!!!!!) and go home. That is what I committed myself to. You on the other hand, with your far more knowledge and training (I will not include intelligence here) have just a few more responsibilities than pulling a few 12 hour shifts! Or even six 12 hour shifts/week (what I have done for the last 3 weeks.)Surely you don't believe that most FP's are taking calls and coming into EDs to assume care. Not where I work now, nor where I have worked in the past 4 years (in other states) has that been the case.Would love to work with more of FP's like you, thoughHugs,RRN

HA! When I was an Anesthesia resident I got called to the ER todo an LP. Not cause it was a difficult one,just that the ER doc[an experienced internist]didn't do them. He wasn't happy when I tossed aside the doo-hicky to measure opening pressure[I truly didn't know what it was for]or whenI offered to set the guy up for anepidural blood patch.

I am a peds resident (just started my PL-2 year and am currently on night float, thankyouverymuch) and this post is perfect. I see both sides of this all the time. We have our own peds ER so we rotate down there as well as doing time (heh) on our three inpatient floors. When we're in the ER, we like to call the admitting resident to let them know we've got a possible admission. Their response is usually, "Do the work up and call us back." When I'm on the floor and the ER calls, my first question after, "Does the patient really need to be admitted?" is "What have you done so far?".

Most of our community docs are great - they direct admit the grand majority of their bili babies (rather than sending a 5 day old through the germtastic ER to get a heel poke for a bili check) and more often than not, they call to ask us if we think the patient needs to come in and what we want them to do before the patient gets to us. It's nice. Of course, most of them also went through our residency program at one point or another. :)

I've decided I want to be a hospitalist when I grow up and during my residency, I'm gunning for procedures as often as possible because I want to be "that gal" during my attending years - the one that does the conscious sedations for CT scans, the one that does the LPs and IVs and helps the residents with such.

The ER is there for a reason: to take care of the emergently sick. The hospitalists also have their place - to manage, diagnose and treat.

doctor bee, bless you. i must say that in my particular facility we have one group of great pediatricians who come in routinely, and another group that doesn't and wants to transfer all sick kids. good luck. you will be a valuable asset to whomever you work for and are already.

This blog underestimates the effect of preventative medicine and its benefits in the primary care arena. Just think about how often ED discharge instructions basically say "you're not going to die tonight so follow up with your primary doctor". Otherwise the admission note might say "You may die and need an ICU now" and in this case an internal medicine specialist will resume care over the next days to weeks in the ICU followed by transition to the medical floor where an IM doc with consulting IM specialists treat the WHOLE patient. As an emergency physician (EP), you have no choice but to treat the emergency- not the patient. You do not have the opportunity, time, or privilege of treating the patient as a whole. Much of the time EPs are unable to get a diagnosis (unless the patient presented with a known condition that was likely diagnosed by a medicine or family doctor), and often the presumptive diagnosis made in the ED turns out to be flat wrong. My point is that glamorizing the procedures and somewhat hasty decisions that occur in the emergency setting is not endearing to anyone who imagines themselves or a loved one as an ED patient. Instead of glamorous, I would describe it as a necessary evil. A family medicine, internist, or cardiologist may not heroically through a breathing tube down a patient's throat on a daily basis but to say that they do not save lives my diagnosing, managing, and PREVENTING the progression of chronic disease is a gross underestimation of their value. Instead, the blogger incredulously pats himself and his emergency medicine colleagues on the derriere.

dear anon., so when did you run your last code? but i digress. i am now a primary care physician, and i now send sick people to the ER. life is good. it's easy. i have time to be thorough. i love it. and when i don't know something i look it up because people are not dying in my clinic. and i did not say the generalist does not save lives... obviously they do, but they can't do nearly as much on the procedural side as they did even twenty years ago. when is the last time you sutured a lac in your office? put on a splint? dug out a splinter? directly admitted a patient? when?

Dear Anon, you ignorant slut..I am not only old and fart a lot but I am by far the dumbest EM Specialist I know..I am so stupid that I have diagnosed BOTH a Pheochromocytoma and Primary Adrenal Insufficiency in the ED that had been missed by the IM, FP, Cardoiologist, and several other "ists" in my career. So take your "I am the diagnostician shit" and stuff it up your ass. And 911, 89 and pretty much every other EM doc I know are smarter than me..